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Verkade HJ, Felzen A, Keitel V, Thompson R, Gonzales E, Strnad P, Kamath B, van Mil S. EASL Clinical Practice Guidelines on genetic cholestatic liver diseases. J Hepatol 2024; 81:303-325. [PMID: 38851996 DOI: 10.1016/j.jhep.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 06/10/2024]
Abstract
Genetic cholestatic liver diseases are caused by (often rare) mutations in a multitude of different genes. While these diseases differ in pathobiology, clinical presentation and prognosis, they do have several commonalities due to their cholestatic nature. These Clinical Practice Guidelines (CPGs) offer a general approach to genetic testing and management of cholestatic pruritus, while exploring diagnostic and treatment approaches for a subset of genetic cholestatic liver diseases in depth. An expert panel appointed by the European Association for the Study of the Liver has created recommendations regarding diagnosis and treatment, based on the best evidence currently available in the fields of paediatric and adult hepatology, as well as genetics. The management of these diseases generally takes place in a tertiary referral centre, in order to provide up-to-date approaches and expertise. These CPGs are intended to support hepatologists (for paediatric and adult patients), residents and other healthcare professionals involved in the management of these patients with concrete recommendations based on currently available evidence or, if not available, on expert opinion.
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Al-Hussaini A, Alrashidi S, Hafez DH, Alkhalifah YS, Otayn B, Alrasheed M, Al Mufarreh S, AlKasim S. Patterns and unique features of infantile cholestasis among Arabs. Front Pediatr 2024; 12:1423657. [PMID: 39139600 PMCID: PMC11319143 DOI: 10.3389/fped.2024.1423657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024] Open
Abstract
Background Most of the literature on infantile cholestasis (IC) originated from Caucasian and Asian populations. The differential diagnosis of IC is very broad, and identification of etiology is challenging to clinicians because the list includes many entities with overlapping clinical, biochemical, and histological features. Thus, a structured, stepwise diagnostic approach is required to help early recognition and prompt evaluation and management of treatable causes of cholestasis. Objective (1) To determine the differential diagnosis of IC among Saudi population and (2) to evaluate the usefulness of a diagnostic algorithm that has been tailored by the authors to the local practice. Methods All infants with onset of cholestasis before 12 months of age (2007 and 2020) were identified and included if they underwent extensive work up to exclude infectious, structural, metabolic, endocrine, infiltrative, and familial causes. Results Our diagnostic pathway allowed a definite diagnosis in 373 of the included 533 cases; 160 (30%) were labelled as "idiopathic neonatal hepatitis" (INH) [i.e., overall 70% detection rate]. However, when considering the cases that underwent extensive investigations including advanced gene testing (415 of the 533), the yield of the diagnostic algorithm was 90% (373/415). Familial cholestasis group was the most common in 20% (107/533), and biliary atresia and neonatal-onset Dubin Johnson syndrome contributed to 6% each. The genetic/hereditary causes of cholestasis contributed to 58% of the diagnosed cases (217/373). No single case of alpha-1 antitrypsin deficiency was diagnosed. Forty-nine infants with cholestasis presented with liver failure (9%). Conclusion Our study highlights several unique features and causes of IC among Arabs which could have a great impact on the differential diagnosis process and the choice of laboratory tests used in the clinical setting.
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Affiliation(s)
- Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Prince Abdullah bin Khalid Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sami Alrashidi
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Deema H. Hafez
- Department of Pediatrics, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Yasir S. Alkhalifah
- Department of Pediatrics, College of Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Bashaer Otayn
- Intensive Care Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majid Alrasheed
- Pediatric Endocrinology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sumayah Al Mufarreh
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sultan AlKasim
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Alhebbi H, El-Edreesi M, Abanemai M, Saadah O, Alhatlani M, Halabi H, Bader R, Sarkhy AA, Aladsani A, Wali S, Alguofi T, Alkhathran N, NasserAllah A, Bashir MS, Al-Hussaini A. Clinical and laboratory features of biliary atresia and patterns of management practices: Saudi national study (2000-2018). Saudi J Gastroenterol 2024; 30:89-95. [PMID: 37706420 PMCID: PMC10980299 DOI: 10.4103/sjg.sjg_151_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND We utilized the data from the Saudi national biliary atresia (BA) study (2000-2018) to describe the clinical, biochemical, imaging, and histopathological features of BA and the perioperative clinical practices among local pediatric gastroenterologists. METHODS This is a retrospective, multicenter, nationwide study that included 10 tertiary care governmental hospitals including the four liver transplant (LT) centers in different regions across Saudi Arabia. RESULTS BA was diagnosed in 204 infants (106 females; 10% preterm). The median age at referral was 65 days. Congenital anomalies were present in 68 patients (33%); 22 were splenic malformation (10.8%). The medians of laboratory investigations were total bilirubin (189 μmol/l), direct bilirubin (139 μmol/l), ALT (164 u/l), and GGT (472 u/l). The level of serum GGT was normal in 26 cases (12.7%). The ultrasound findings included hypoplastic or atrophic gall bladder (GB) (65%), normal GB (30%), and cord sign (5%). A HIDA scan was performed in 99 cases (48.52%). Magnetic resonance cholangiopancreatography (MRCP) was performed in 27 cases (13%). A total of 179 liver biopsies (88%) were obtained. The most common histopathologic findings were bile duct proliferation (92%), canalicular cholestasis (96%), bile plugs (84%), and portal fibrosis (95%). Cholangiography was performed in 139 cases (68%): operative in 122 (60%) and percutaneous in 17 (8%). A total of 143 children (70%) underwent Kasai portoenterostomy (KPE) at a median age of 70 days. After KPE, steroid was used in 37% of the cases and 100 cases (70%) were prescribed prophylactic antibiotics for variable duration (ranging between 3 and 12 months). CONCLUSION Our data show marked variation in the diagnostic evaluation and perioperative management of BA cases among the different tertiary centers. There is a need to establish a national BA registry in Saudi Arabia aiming to standardize pre- and postoperative clinical practices. Additionally, normal serum GGT level, normal GB size on ultrasound, and being a premature baby should not preclude the diagnostic workup for BA.
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Affiliation(s)
- Homoud Alhebbi
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed El-Edreesi
- Division of Pediatric Gastroenterology, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Mohammed Abanemai
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omar Saadah
- Division of Pediatric Gastroenterology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maher Alhatlani
- Al Imam Abdulrahman Bin Faisal Hospital, Ministry of National Guard Health Affairs, Dammam, Saudi Arabia
| | - Hana Halabi
- Maternity and Children’s Hospital, Makkah, Saudi Arabia
| | - Razan Bader
- Multi-organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed Al Sarkhy
- Department of Pediatrics, Gastroenterology Division, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Aladsani
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sami Wali
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Talal Alguofi
- Organ Transplant Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nawaf Alkhathran
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Muhammed Salman Bashir
- Department of Biostatistics, Research Services Administration, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Prince Abdullah Bin Khaled Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
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Gardin A, Ruiz M, Beime J, Cananzi M, Rathert M, Rohmer B, Grabhorn E, Almes M, Logarajah V, Peña-Quintana L, Casswall T, Darmellah-Remil A, Reyes-Domínguez A, Barkaoui E, Hierro L, Baquero-Montoya C, Baumann U, Fischler B, Gonzales E, Davit-Spraul A, Laplanche S, Jacquemin E. ∆ 4-3-oxo-5β-reductase deficiency: favorable outcome in 16 patients treated with cholic acid. Orphanet J Rare Dis 2023; 18:383. [PMID: 38062451 PMCID: PMC10704681 DOI: 10.1186/s13023-023-02984-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/18/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Oral cholic acid therapy is an effective therapy in children with primary bile acid synthesis deficiencies. Most reported patients with this treatment have 3β-hydroxy-Δ5-C27-steroid oxidoreductase deficiency. The aim of the study was the evaluation of cholic acid therapy in a cohort of patients with the rarer Δ4-3-oxosteroid 5β-reductase (Δ4-3-oxo-R) deficiency. METHODS Sixteen patients with Δ4-3-oxo-R deficiency confirmed by AKR1D1 gene sequencing who received oral cholic acid were retrospectively analyzed. RESULTS First symptoms were reported early in life (median 2 months of age), with 14 and 3 patients having cholestatic jaundice and severe bleeding respectively. Fifteen patients received ursodeoxycholic acid before diagnosis, with partial improvement in 8 patients. Four patients had liver failure at the time of cholic acid initiation. All 16 patients received cholic acid from a median age of 8.1 months (range 3.1-159) and serum liver tests normalized in all within 6-12 months of treatment. After a median cholic acid therapy of 4.5 years (range 1.1-24), all patients were alive with their native liver. Median daily cholic acid dose at last follow-up was 8.3 mg/kg of body weight. All patients, but one, had normal physical examination and all had normal serum liver tests. Fibrosis, evaluated using liver biopsy (n = 4) or liver elastography (n = 9), had stabilized or improved. Cholic acid therapy enabled a 12-fold decrease of 3-oxo-∆4 derivatives in urine. Patients had normal growth and quality of life. The treatment was well tolerated without serious adverse events and signs of hepatotoxicity. CONCLUSIONS Oral cholic acid therapy is a safe and effective treatment for patients with Δ4-3-oxo-R deficiency.
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Affiliation(s)
- Antoine Gardin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FSMR Filfoie, ERN RARE LIVER, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine Paris-Saclay, Le Kremlin-Bicêtre; INSERM UMR-S1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Mathias Ruiz
- Pediatric Hepatology, Gastroenterology and Nutrition Unit, Reference Centre for Biliary Atresia and Genetic Cholestasis, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, Bron, France
| | - Jan Beime
- Pediatric Hepatology and Gastroenterology Unit, University Hamburg-Eppendorf, Hamburg, Germany
| | - Mara Cananzi
- Unit of Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Dpt. For Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Margarete Rathert
- Pediatric Hepatology, Gastroenterology and Nutrition Unit, MHH Hannover/University Magdeburg, Hannover, Germany
| | - Barbara Rohmer
- Pediatric Hepatology, Gastroenterology and Nutrition Unit, Reference Centre for Biliary Atresia and Genetic Cholestasis, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, Bron, France
| | - Enke Grabhorn
- Pediatric Hepatology and Gastroenterology Unit, University Hamburg-Eppendorf, Hamburg, Germany
| | - Marion Almes
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FSMR Filfoie, ERN RARE LIVER, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine Paris-Saclay, Le Kremlin-Bicêtre; INSERM UMR-S1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Veena Logarajah
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KK Women's and Children's Hospital, Singapore, Singapore
| | - Luis Peña-Quintana
- Paediatric Gastroenterology, Hepatology and Nutrition Unit. Complejo Hospitalario Universitario Insular Materno-Infantil, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Thomas Casswall
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Astrid Lindgren's Children's Hospital, CLINTEC, Karolinska Institutet, Karolinska University, Stockholm, Sweden
| | - Amaria Darmellah-Remil
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FSMR Filfoie, ERN RARE LIVER, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine Paris-Saclay, Le Kremlin-Bicêtre; INSERM UMR-S1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Ana Reyes-Domínguez
- Paediatric Gastroenterology, Hepatology and Nutrition Unit. Complejo Hospitalario Universitario Insular Materno-Infantil, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Emna Barkaoui
- Department of Pediatrics, Tunis Children Hospital, Tunis, Tunisia
| | - Loreto Hierro
- Pediatric Hepatology Unit, University Hospital La Paz, Madrid, Spain
| | | | - Ulrich Baumann
- Pediatric Hepatology, Gastroenterology and Nutrition Unit, MHH Hannover/University Magdeburg, Hannover, Germany
| | - Björn Fischler
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Astrid Lindgren's Children's Hospital, CLINTEC, Karolinska Institutet, Karolinska University, Stockholm, Sweden
| | - Emmanuel Gonzales
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FSMR Filfoie, ERN RARE LIVER, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine Paris-Saclay, Le Kremlin-Bicêtre; INSERM UMR-S1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Anne Davit-Spraul
- Biochemistry Department, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Sophie Laplanche
- Biology Unit, Groupe Hospitalier Paris - Saint Joseph, Paris, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FSMR Filfoie, ERN RARE LIVER, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Faculty of Medicine Paris-Saclay, Le Kremlin-Bicêtre; INSERM UMR-S1193, Hepatinov, University Paris-Saclay, Orsay, France.
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Muto Y, Suzuki M, Takei H, Saito N, Mori J, Sugimoto S, Imagawa K, Nambu R, Oguri S, Itonaga T, Ihara K, Hayashi H, Murayama K, Kakiyama G, Nittono H, Shimizu T. Dried blood spot-based newborn screening for bile acid synthesis disorders, Zellweger spectrum disorder, and Niemann-Pick type C1 by detection of bile acid metabolites. Mol Genet Metab 2023; 140:107703. [PMID: 37802748 DOI: 10.1016/j.ymgme.2023.107703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To examine whether it is possible to screen for bile acid synthesis disorders (BASDs) including peroxisome biogenesis disorder 1a (PBD1A) and Niemann-Pick type C1 (NPC1) at the time of newborn mass screening by measuring the intermediary metabolites of bile acid (BA) synthesis. METHODS Patients with 3β-hydroxy-ΔSuchy et al. (2021)5-C27-steroid dehydrogenase/isomerase (HSD3B7) deficiency (n = 2), 3-oxo-ΔPandak and Kakiyama (n.d.)4-steroid 5β-reductase (SRD5B1) deficiency (n = 1), oxysterol 7α-hydroxylase (CYP7B1) deficiency (n = 1), PBD1A (n = 1), and NPC1 (n = 2) with available dried blood spot (DBS) samples collected in the neonatal period were included. DBSs from healthy neonates at 4 days of age (n = 1055) were also collected for the control. Disease specific BAs were measured by newly optimized liquid chromatography-tandem mass spectrometry with short run cycle (5-min/run). The results were validated by comparing with those obtained by the conventional condition with longer run cycle (76-min/run). RESULTS In healthy specimens, taurocholic acid and cholic acid were the two major BAs which constituted approximately 80% in the measured BAs. The disease marker BAs presented <10%. In BASDs, the following BAs were determined for the disease specific markers: Glyco/tauro 3β,7α,12α-trihydroxy-5-cholenoic acid 3-sulfate for HSD3B7 deficiency (>70%); glyco/tauro 7α,12α-dihydroxy-3-oxo-4-cholenoic acid for SRD5B1 deficiency (54%); tauro 3β-hydroxy-5-cholenoic acid 3-sulfate for CYP7B1 deficiency (94%); 3α,7α,12α-trihydroxy-5β-cholestanoic acid for PBD1A (78%); and tauro 3β,7β-dihydroxy-5-cholenoic acid 3-sulfate for NPC1 (26%). *The % in the parenthesis indicates the portion found in the patient's specimen. CONCLUSIONS Early postnatal screening for BASDs, PBD1A and NPC1 is feasible with the described DBS-based method by measuring disease specific BAs. The present method is a quick and affordable test for screening for these inherited diseases.
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Affiliation(s)
- Yamato Muto
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
| | - Hajime Takei
- Junshin Clinic Bile Acid Institute, 2-1-24 Haramachi, Meguro-ku, Tokyo 152-0011, Japan
| | - Nobutomo Saito
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Jun Mori
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Satoru Sugimoto
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kazuo Imagawa
- Department of Child Health, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology & Hepatology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city 330-8777, Japan
| | - Saori Oguri
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Kenji Ihara
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Hisamitsu Hayashi
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Science, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Kei Murayama
- Diagnostics and Therapeutics of Intractable Diseases, Intractable Disease Research Center, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Genta Kakiyama
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1101 E. Marshall St., Richmond, VA 23298, USA; Central Virginia VA Healthcare System, 1201 Broad Rock Blvd., Richmond, VA 23249, USA
| | - Hiroshi Nittono
- Junshin Clinic Bile Acid Institute, 2-1-24 Haramachi, Meguro-ku, Tokyo 152-0011, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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Farooqui N, Elhence A, Shalimar. A Current Understanding of Bile Acids in Chronic Liver Disease. J Clin Exp Hepatol 2022; 12:155-173. [PMID: 35068796 PMCID: PMC8766695 DOI: 10.1016/j.jceh.2021.08.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/16/2021] [Indexed: 01/03/2023] Open
Abstract
Chronic liver disease (CLD) is one of the leading causes of disability-adjusted life years in many countries. A recent understanding of nuclear bile acid receptor pathways has increased focus on the impact of crosstalk between the gut, bile acids, and liver on liver pathology. While conventionally used in cholestatic disorders and to dissolve gallstones, the discovery of bile acids' influence on the gut microbiome and human metabolism offers a unique potential for their utility in early and advanced liver diseases because of diverse etiologies. Based on these findings, preclinical studies using bile acid-based molecules have shown encouraging results at addressing liver inflammation and fibrosis. Emerging data also suggest that bile acid profiles change distinctively across various causes of liver disease. We summarize the current knowledge and evidence related to bile acids in health and disease and discuss culminated and ongoing therapeutic trials of bile acid derivatives in CLD. In the near future, further evidence in this area might help clinicians better detect and manage liver diseases.
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Key Words
- AD, Acute decompensation
- ALP, Alkaline phosphatase
- AMACR, α-methylacyl-CoA racemase (AMACR)
- ASBT, Apical sodium dependent bile salt transporter
- BA, Bile acid
- BSEP, Bile salt export pump
- BSH, Bile salt hydrolase
- CA, Cholic acid
- CDCA, Chenodeoxycholic acid
- CLD
- CLD, Chronic Liver Disease
- CTP, Child-Turcotte-Pugh
- CYP7A1, Cholesterol 7 α hydroxylase
- DCA, Deoxycholic acid
- DR5, Death receptor 5
- ELF, Enhanced Liver Fibrosis
- FGF-19, Fibroblast growth factor-19
- FGFR4, FGF receptor 4
- FXR, Farnesoid X receptor
- GCA, Glycocholic acid
- GDCA, Glycodeoxycholic acid
- GLP-1, Glucagon-like peptide1
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HVPG, Hepatic Venous Pressure Gradient
- LCA, Lithocholic acid
- LPS, Lipopolysaccharide
- MELD, Model for End-Stage Liver Disease (MELD)
- MRI-PDFF, Magnetic resonance imaging derived proton density fat fraction
- NAFLD
- NAFLD, Non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, Nonalcoholic steatohepatitis
- NTCP, Sodium taurocholate cotransporting polypeptide
- OCA, Obeticholic acid
- OST, Organic solute transporter
- PBC, Primary biliary cirrhosis
- PFIC, Progressive familial intrahepatic cholestasis
- PSC, Primary sclerosing cholangitis
- PXR, Pregnane X receptor
- SHP, Small heterodimer partner
- TBA, Total bile acids
- TGR5, Takeda G-protein coupled receptor 5
- TRAIL, TNF-related apoptosis-inducing ligand
- UDCA, Ursodeoxycholic acid
- UPLC-MS, Ultra-performance liquid chromatography with tandem mass spectrometry
- VDR, Vitamin D receptor
- bile acids
- cirrhosis
- microbiome
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Affiliation(s)
- Naba Farooqui
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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7
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Kimura A, Mizuochi T, Takei H, Ohtake A, Mori J, Shinoda K, Hashimoto T, Kasahara M, Togawa T, Murai T, Iida T, Nittono H. Bile Acid Synthesis Disorders in Japan: Long-Term Outcome and Chenodeoxycholic Acid Treatment. Dig Dis Sci 2021; 66:3885-3892. [PMID: 33385262 DOI: 10.1007/s10620-020-06722-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND We encountered 7 Japanese patients with bile acid synthesis disorders (BASD) including 3β-hydroxy-Δ5-C27-steroid dehydrogenase/isomerase (3β-HSD) deficiency (n = 3), Δ4-3-oxosteroid 5β-reductase (5β-reductase) deficiency (n = 3), and oxysterol 7α-hydroxylase deficiency (n = 1) over 21 years between 1996 and 2017. AIM We aimed to clarify long-term outcome in the 7 patients with BASD as well as long-term efficacy of chenodeoxycholic acid (CDCA) treatment in the 5 patients with 3β-HSD deficiency or 5β-reductase deficiency. METHODS Diagnoses were made from bile acid and genetic analyses. Bile acid analysis in serum and urine was performed using gas chromatography-mass spectrometry. Clinical and laboratory findings and bile acid profiles at diagnosis and most recent visit were retrospectively obtained from medical records. Long-term outcome included follow-up duration, treatments, growth, education/employment, complications of treatment, and other problems. RESULTS Medians with ranges of current patient ages and duration of CDCA treatment are 10 years (8 to 43) and 10 years (8 to 21), respectively. All 7 patients, who had homozygous or compound heterozygous mutations in the HSD3B7, SRD5B1, or CYP7B1 gene, are currently in good health without liver dysfunction. In the 5 patients with CDCA treatment, hepatic function gradually improved following initiation. No adverse effects were noted. CONCLUSIONS We concluded that CDCA treatment is effective in 3β-HSD deficiency and 5β-reductase deficiency, as cholic acid has been in other countries. BASD carry a good prognosis following early diagnosis and initiation of long-term CDCA treatment.
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Affiliation(s)
- Akihiko Kimura
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
- Kumamoto-Ashikita Medical Center for the Severely Disabled, Kumamoto, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan.
| | - Hajime Takei
- Junshin Clinic Bile Acid Institute, Tokyo, Japan
| | - Akira Ohtake
- Department of Pediatrics and Clinical Genomics, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Jun Mori
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Takuji Hashimoto
- Department of Pediatrics, Toho University School of Medicine, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takao Togawa
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tsuyoshi Murai
- School of Pharmaceutical Sciences, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Takashi Iida
- Department of Chemistry, College of Humanities and Science, Nihon University, Tokyo, Japan
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8
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Zhao J, Setchell KDR, Gong Y, Sun Y, Zhang P, Heubi JE, Fang L, Lu Y, Xie X, Gong J, Wang JS. Genetic spectrum and clinical characteristics of 3β-hydroxy-Δ 5-C 27-steroid oxidoreductase (HSD3B7) deficiency in China. Orphanet J Rare Dis 2021; 16:417. [PMID: 34627351 PMCID: PMC8501698 DOI: 10.1186/s13023-021-02041-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/19/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Biallelic variants in HSD3B7 cause 3β-hydroxy-Δ5-C27-steroid oxidoreductase (HSD3B7) deficiency, a life-threatening but treatable liver disease. The goal of this study was to obtain detailed information on the correlation between the genotype and phenotype of HSD3B7 deficiency and to report on responses to primary bile acid therapy. METHODS The medical records of a cohort of 39 unrelated patients with genetically and biochemically confirmed HSD3B7 deficiency were examined to determine whether there exist genotype-phenotype relationships in this bile acid synthesis disorder. RESULTS In all, 34 of the 44 variants identified in HSD3B7 were novel. A total of 32 patients presented early with neonatal cholestasis, and 7 presented after 1-year of age with liver failure (n = 1), liver cirrhosis (n = 3), cholestasis (n = 1), renal cysts and abnormal liver biochemistries (n = 1), and coagulopathy from vitamin K1 deficiency and abnormal liver biochemistries (n = 1). Renal lesions, including renal cysts, renal stones, calcium deposition and renal enlargement were observed in 10 of 35 patients. Thirty-three patients were treated with oral chenodeoxycholic acid (CDCA) resulting in normalization of liver biochemistries in 24, while 2 showed a significant clinical improvement, and 7 underwent liver transplantation or died. Remarkably, renal lesions in 6 patients resolved after CDCA treatment, or liver transplantation. There were no significant correlations between genotype and clinical outcomes. CONCLUSIONS In what is the largest cohort of patients with HSD3B7 deficiency thus far studied, renal lesions were a notable clinical feature of HSD3B7 deficiency and these were resolved with suppression of atypical bile acids by oral CDCA administration.
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Affiliation(s)
- Jing Zhao
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Kenneth D R Setchell
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ying Gong
- Department of Radiology, Children's Hospital of Fudan University, Shanghai, China
| | - Yinghua Sun
- Department of Ultrasonography, Children's Hospital of Fudan University, Shanghai, China
| | - Ping Zhang
- Center for Molecular Medicine, Pediatrics Research Institute, Children's Hospital of Fudan University, Shanghai, China
| | - James E Heubi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lingjuan Fang
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Yi Lu
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Xinbao Xie
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Jingyu Gong
- Department of Pediatrics, Jinshan Hospital of Fudan University, Shanghai, China
| | - Jian-She Wang
- The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
- Shanghai Key Laboratory of Birth Defect, Shanghai, China.
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9
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Abstract
OBJECTIVES The published data on early infantile liver failure (EILF) are scarce and limited to Caucasians. We conducted this study to describe the etiology and outcome of EILF among Arabs and identify prognostic factors. METHODS We retrospectively reviewed our database of 524 infants presenting with liver impairment from 2008 to 2018, and identified cases of EILF defined as presence of biochemical pattern of liver disease and INR ≥2 (unresponsive to vitamin K) with onset before 3 months of life. Primary outcomes included death or liver transplantation (LT) (poor outcome group) and survival with native liver (good outcome group). RESULTS Forty-two cases of EILF (22 girls) were identified (8%). The etiology was indeterminate in 14 (33.3%) and established in 27 (64.3%): galactosemia (7 cases, 16.6%), tyrosinemia (5, 12%), neonatal hemochromatosis (NH), and hemophagocytic lymphohistiocytosis (HLH) (4 each, 9.5%]) mitochondrial hepatopathy (3, 7%), and miscellaneous (5, 12%). LF resolved in 15 cases (35.7%), either spontaneously or in response to specific therapy, 23 (54.7%) died, and 4 underwent LT (9.5%). ROC analysis for the best cut-off value of serum total bilirubin for prediction of study outcomes was 120 μmol/L (sensitivity 81.5%, specificity 80%). Among the diagnostic groups, galactosemia and tyrosinemia predicted good outcome, whereas the idiopathic diagnosis predicted poor outcome (OR = 13). CONCLUSIONS Similar to Western countries, galactosemia, tyrosinemia, NH, HLH, and mitochondrial hepatopathy are the main players in EILF in Saudi Arabia. Galactosemia and tyrosinemia predict good prognosis and idiopathic diagnosis predicts poor prognosis.
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10
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Ravindranath A, Sen Sarma M, Yachha SK. Bile acid synthetic defects: Simplified approach in a nutshell. Hepatobiliary Pancreat Dis Int 2020; 19:80-84. [PMID: 31558365 DOI: 10.1016/j.hbpd.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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11
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Zhang MH, Setchell KDR, Zhao J, Gong JY, Lu Y, Wang JS. Δ4-3-oxosteroid-5β-reductase deficiency: Responses to oral bile acid therapy and long-term outcomes. World J Gastroenterol 2019; 25:859-869. [PMID: 30809085 PMCID: PMC6385010 DOI: 10.3748/wjg.v25.i7.859] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Disorders of primary bile acid synthesis may be life-threatening if undiagnosed, or not treated with primary bile acid replacement therapy. To date, there are few reports on the management and follow-up of patients with Δ4-3-oxosteroid 5β-reductase (AKR1D1) deficiency. We hypothesized that a retrospective analysis of the responses to oral bile acid replacement therapy with chenodeoxycholic acid (CDCA) in patients with this bile acid synthesis disorder will increase our understanding of the disease progression and permit evaluation of this treatment regimen as an alternative to the Food and Drug Administration (FDA) approved drug cholic acid, which is currently unavailable in China.
AIM To evaluate the therapeutic responses of patients with AKR1D1 deficiency to oral bile acid therapy, specifically CDCA.
METHODS Twelve patients with AKR1D1 deficiency, confirmed by fast atom bombardment ionization-mass spectrometry analysis of urine and by gene sequencing for mutations in AKR1D1, were treated with differing doses of CDCA or ursodeoxycholic acid (UDCA). The clinical and biochemical responses to therapy were monitored over a period ranging 0.5-6.4 years. Dose adjustment, to optimize the therapeutic dose, was based on changes in serum biochemistry parameters, notably liver function tests, and suppression of the urinary levels of atypical hepatotoxic 3-oxo-Δ4-bile acids measured by mass spectrometry.
RESULTS Physical examination, serum biochemistry parameters, and sonographic findings improved in all 12 patients during bile acid therapy, except one who underwent liver transplantation. Urine bile acid analysis confirmed a significant reduction in atypical hepatotoxic 3-oxo-Δ4 bile acids concomitant with clinical and biochemical improvements in those patients treated with CDCA. UDCA was ineffective in down-regulating endogenous bile acid synthesis as evidenced from the inability to suppress the urinary excretion of atypical 3-oxo-Δ4-bile acids. The dose of CDCA required for optimal clinical and biochemical responses varied from 5.5-10 mg/kg per day among patients based on maximum suppression of the atypical bile acids and improvement in serum biochemistry parameters, and careful titration of the dose was necessary to avoid side effects from CDCA.
CONCLUSION The primary bile acid CDCA is effective in treating AKR1D1 deficiency but the therapeutic dose requires individualized optimization. UDCA is not recommended for long-term management.
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Affiliation(s)
- Mei-Hong Zhang
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Kenneth DR Setchell
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Jing Zhao
- The Center for Pediatric Liver Diseases, Children’s Hospital of Fudan University, Shanghai 201102, China
- Department of Pediatrics, Shanghai Medical College of Fudan University, Shanghai 201102, China
| | - Jing-Yu Gong
- Department of Pediatrics, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Yi Lu
- The Center for Pediatric Liver Diseases, Children’s Hospital of Fudan University, Shanghai 201102, China
- Department of Pediatrics, Shanghai Medical College of Fudan University, Shanghai 201102, China
| | - Jian-She Wang
- The Center for Pediatric Liver Diseases, Children’s Hospital of Fudan University, Shanghai 201102, China
- Department of Pediatrics, Shanghai Medical College of Fudan University, Shanghai 201102, China
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12
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Abstract
Inborn errors of bile acid metabolism are rare causes of neonatal cholestasis and liver disease in older children and adults. The diagnosis should be considered in the context of hyperbilirubinemia with normal serum bile acids and made by urinary liquid secondary ionization mass spectrometry or DNA testing. Cholic acid is an effective treatment of most single-enzyme defects and patients with Zellweger spectrum disorder with liver disease.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA.
| | - Kenneth D R Setchell
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
| | - Kevin E Bove
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
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13
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Gonzales E, Matarazzo L, Franchi-Abella S, Dabadie A, Cohen J, Habes D, Hillaire S, Guettier C, Taburet AM, Myara A, Jacquemin E. Cholic acid for primary bile acid synthesis defects: a life-saving therapy allowing a favorable outcome in adulthood. Orphanet J Rare Dis 2018; 13:190. [PMID: 30373615 PMCID: PMC6206929 DOI: 10.1186/s13023-018-0920-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 09/24/2018] [Indexed: 02/08/2023] Open
Abstract
Background Oral cholic acid (CA) replacement has been shown to be an effective therapy in children with primary bile acid synthesis defects, which are rare and severe genetic liver diseases. To date there has been no report of the effects of this therapy in children reaching adulthood. The aim of the study was to evaluate the long-term effectiveness and safety of CA therapy. Methods Fifteen patients with either 3β-hydroxy-Δ5-C27-steroid oxidoreductase (3β-HSD) (n = 13) or Δ4–3-oxosteroid 5β-reductase (Δ4–3-oxo-R) (n = 2) deficiency confirmed by mass spectrometry and gene sequencing received oral CA and were followed prospectively. Results The median age at last follow-up and the median time of follow-up with treatment were 24.3 years (range: 15.3–37.2) and 21.4 years (range: 14.6–24.1), respectively. At last evaluation, physical examination findings and blood laboratory test results were normal in all patients. Liver sonograms were normal in most patients. Mean daily CA dose was 6.9 mg/kg of body weight. Mass spectrometry analysis of urine showed that excretion of the atypical metabolites remained low or traces in amount with CA therapy. Liver fibrosis scored in liver biopsies or assessed by elastography in 14 patients, after 10 to 24 years with CA therapy, showed a marked improvement with disappearance of cirrhosis (median score < F1; range: F0-F2). CA was well tolerated in all patients, including five women having 10 uneventful pregnancies during treatment. Conclusions Oral CA therapy is a safe and effective long-term treatment of 3β-HSD and Δ4–3-oxo-R deficiencies and allows affected children to reach adulthood in good health condition without the need for a liver transplantation.
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Affiliation(s)
- Emmanuel Gonzales
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France.,Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,INSERM UMR-S1174 and Hepatinov, University Paris -Sud / Paris - Saclay, Orsay, France.,Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Hôpital Bicêtre, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, France
| | | | - Stéphanie Franchi-Abella
- Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,Pediatric Radiology Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alain Dabadie
- Department of Pediatrics, Hôpital Sud, Rennes, France
| | - Joseph Cohen
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dalila Habes
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Hillaire
- Hepatology Unit, Hôpital Foch, and Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Catherine Guettier
- Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France.,Pathology Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Anne-Marie Taburet
- Pharmacy Unit, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Anne Myara
- Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, National Reference Centre for rare pediatric liver diseases and Filfoie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France. .,Faculty of Medicine Paris - Sud, University Paris - Sud / Paris - Saclay, Paris, France. .,INSERM UMR-S1174 and Hepatinov, University Paris -Sud / Paris - Saclay, Orsay, France.
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